ABSTRACT NUMBER: ESOC2026A1477 PERI-PROCEDURAL ANTICOAGULATION MANAGEMENT IN PATIENTS RECEIVING DIRECT ORAL ANTICOAGULANTS OR WARFARIN: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background and aims Peri-procedural management of anticoagulation remains challenging due to the need to balance bleeding and thromboembolic risks, particularly with increasing use of direct oral anticoagulants (DOACs). This systematic review and meta-analysis evaluated contemporary evidence comparing peri-procedural management strategies for DOACs and warfarin, with relevance to UK and Ireland clinical practice. Methods A comprehensive search (2014–2025) identified 29 studies (8 meta-analyses, 6 randomized controlled trials, 10 cohort studies, and 5 registry analyses) including approximately 40,000 patients undergoing invasive procedures. Primary outcomes were 30-day major bleeding and thromboembolic events. Random-effects meta-analysis and standard risk-of-bias tools were applied in accordance with PRISMA guidance. Results Across studies of DOAC interruption, pooled 30-day major bleeding was 1.81% and thromboembolism 0.41%, indicating low absolute event rates. In direct comparisons, uninterrupted or minimally interrupted DOAC strategies were associated with significantly lower major bleeding compared with warfarin (OR 0.71), particularly in atrial fibrillation catheter ablation. For cardiac implantable electronic device procedures, interrupted and uninterrupted anticoagulation strategies showed no significant differences in bleeding or thromboembolic outcomes, although certainty of evidence was low. Routine heparin bridging did not reduce thromboembolic risk and was associated with increased bleeding. Conclusions Overall, peri-procedural DOAC management is associated with favorable safety outcomes, and uninterrupted or minimally interrupted strategies appear safer than warfarin for selected procedures. These findings support guideline-endorsed, individualized approaches based on procedural bleeding risk, DOAC pharmacokinetics, and renal function, while discouraging routine bridging anticoagulation. Conflict of interest Ramsha Khan nothing to disclose